Online Application

 

Below is an on-line application that you can fill out and send to us. You are not obligated to work for us by filling out application. It simply lets Medsense La, LLC find an ideal job for you when you are ready to work. Please fill out completely. We will contact you within a few days to discuss possible assignments or per diem work. Call us toll-free at 1-866-696-3484 for any questions or comments.

Application for Employment

Date:

PERSONAL

Name: SSN: (optional)

Present Address:

City:State:Zip Code:

Home Telephone:     Other Telephone:

Email Address

Yes  No        Have you ever worked for Medsense LA, LLC previously?

Yes  No        Have you ever applied with Medsense LA, LLC before?

Yes  No        Are you 18 years of age or older?

Yes  No        Do you have the right to work in the U.S.?

Yes  No        Have you ever been convicted of a felony offense? If yes, explain in the space below.

How did you hear about Medsense LA, LLC?

Referred by:

Job(s) applying for: 1.Rate of Pay Expected:

                                    2.Rate of Pay Expected:

Shifts available for work:    7a-3p    3p-11p    11p-7a    7a-7p    7p-7a

Days available to work:    Mon.  Tues.  Wed.  Thurs.  Fri.  Sat.  Sun.

Type of position desired:    Full time    Part time

Date available to begin work:

Educational Background

College name:

Month/Year Graduated:

City, State:       

Diplomas/Degrees Received:

Other School:

Month/Year Graduated:

City, State:      

Diplomas/Degrees Received:

Other School:

Month/Year Graduated:

City, State:     

Diplomas/Degrees Received:

Work History
Start With Most Recent Employment Information:
Name/Employer:
Department:
Street Address:
City:
State:        ZIP:
Dates Employed: From:        To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other phone:
May we contact: Yes   No

 
2nd Employment Information:
Name/Employer:
Department:
Street Address:
City:
State:        ZIP:
Dates Employed: From:        To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other phone:
May we contact: Yes   No

 
3rd Employment Information:
Name/Employer:
Department:
Street Address:
City:
State:        ZIP:
Dates Employed: From:        To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other phone:
May we contact: Yes   No

 
4th Employment Information:
Name/Employer:
Department:
Street Address:
City:
State:        ZIP:
Dates Employed: From:        To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other phone:
May we contact: Yes   No

 
5th Employment Information:
Name/Employer:
Department:
Street Address:
City:
State:        ZIP:
Dates Employed: From:        To:
Reason for leaving:
Position held:
Specialty:
Supervisor's name & title:
Supervisor's phone:
Other phone:
May we contact: Yes   No

Licenses/Certification
Type of Certification/License
 License #

Certifying/Licensing Agency

Expiration Date

Type of Certification/License
  License #

Certifying/Licensing Agency

Expiration Date

Type of Certification/License
  License #

Certifying/Licensing Agency

Expiration Date

 

References
Name:
Company:
Phone:
Relationship:

Name:
Company:
Phone:
Relationship:

Name:
Company:
Phone:
Relationship:

 

Please Read Carefully
Applicant's Certification and Agreement

If employed by medsense LLC, I will abide by its rules and regulations. I also agree to physical and medical examinations and/or tests at any time as permitted by law and agree that the examining physician may disclose to the Company or its representatives the results.

            I give the Company my permission to conduct any investigation regarding the information contained in my employment application which the Company deems necessary to determine my qualifications for assuming a job with the company. I give the Company my permission to contact any police (city and state) and judicial jurisdictions, including the Federal Bureau of Investigation, former employer, school, college or university, credit or finance bureau or office, any personal or professional reference, or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that such sources may have about my character, general reputation or credit, criminal, education, or employment record. I also unconditionally release the Company and all named and unnamed sources from any and all liability which might arise from furnishing any information about me.

            All of the foregoing information I have supplied in this application is a full and complete statement of the facts, and it is understood that if any falsification be discovered, it will constitute grounds for non-hire or dismissal upon discovery thereof, I also understand that this application is not a contract of employment and that if I am employed by medsense LLC, I will be an at-will employee and I may voluntarily leave my employment or my employment may be terminated by medsense LLC, at any time for any reason. I acknowledge that no contrary written or oral statements have been made to or relied upon by me regarding the length of my employment with medsense LLC, or the reasons for which my employment can be terminated.

Please check the box below to confirm your agreement with the terms set forth above.

   By checking this box, you are confirming that the information given on this application is accurate and you have read the agreement above.

 

 

Copyright ©2003. Medsense LA, LLC. All Rights Reserved.